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Early Experiences from an NHS Clinical Chemist working in the US

The role of the clinical chemist is changing. Regardless of where you are plying your trade, it is becoming increasingly challenging for young people in the profession to effectively carry out the job they were trained to do. Sadly, nowhere is this more evident than in the National Health Service (NHS). In recent years, the traditional the role of the clinical scientist in the NHS has become threatened from various quarters. Perhaps the biggest challenge has been the increasing presence of private involvement in pathology. Consequently, we’ve witnessed a huge shift towards an emphasis on the “added value” of our contribution to patient management. However, when cost becomes king, it is difficult to argue the benefits of a quality-driven service. All of this can be overwhelming for young people in the profession, particularly when a lot of the “older generation” unashamedly tell us that they are glad to be, “getting out” as they come to the end of their careers. On a positive note, I personally believe that the trainees within the NHS are of a very high calibre. But even our training is not immune to cost-cutting, with widespread changes now in place as part of the Modernising Scientific Careers overhaul. The good news is that NHS clinical chemists have largely attained the knowledge and highly transferable skills to thrive anywhere. And I think that the supply line of young scientists looking to pursue a career in clinical chemistry is unlikely to decrease, as a result of our unique position in being able to offer flexibility and security, something academia is not renowned for. The only limiting factor for these people is the unfortunate fact that trainee posts are drying up out there, and when they are advertised are more competitive than ever.

In the US, The fellowship training program typically lasts 2 years. This is in contrast to the traditional NHS clinical scientist pre-registration programs, which tend to last at minimum 3 to 4 years, culminating in state registration with the Health Professions Council. In addition, an MSc in clinical biochemistry is also achieved during this time period through part-time learning. In the US, there is no such academic component. Also, in contrast to the UK, a PhD is an absolute requirement for entry in the US. The commission on accreditation for clinical chemistry (COMACC) (www.comacc.org/Pages/default.aspx) is responsible for validating training for clinical chemists in the US.

The training programs themselves offer slightly different approaches in the two countries. In the UK, I think the training is more clinically orientated, with a large emphasis on how to interpret results and offer advice on test requisition and results interpretation. This role of “clinical validation” is a significant component of the NHS biochemist’s weekly duties. This offers an opportunity to directly influence the requestor by various mechanisms such as commenting on results, telephone conversations and in some cases, reflective addition of tests that may further help the requestor to answer their clinical question. In the US, the medical technologists are largely responsible for releasing results following technical validation. The additional value of the clinical validation process is much more limited. This is clearly a consequence of the differing healthcare set-up in the US, where there is a culture of “over-requesting” with little effort on the part of laboratories to act as gatekeepers, although this may be set to change in the future.

The UK training also seems to offer more opportunities for clinical liaison (ward round and clinic attendance). In the majority of cases, clinical chemists will be training alongside chemical pathology registrars (medically trained biochemists) who are able to offer to the former much of their clinical knowledge. Both UK and US programs are able to offer flexibility and an opportunity to develop and optimise training according to your own requirements. For example, in my case, I came into the US fellowship with prior experience working as a clinical biochemist in the NHS. As a result, my focus is less on the clinical service and more on research and development.

For those currently working as clinical scientists in the NHS who fancy a career in the US, the COMACC route is a great place to start. My prior clinical laboratory experience undoubtedly helped with my acceptance into the program. I suspect that it would be much more difficult to come to the US on a working visa having no such experience. Alternatively, there may also be an option to apply for associate director jobs across the pond directly. However, most centres will only consider candidates holding certification with the American Board of Clinical Chemistry (ABCC). In my opinion, for those with some clinical lab experience, the COMACC approach is the ideal way to work in the US. Whether the objective is to do some research, or to prepare for a career in the US, most programs are flexible enough to manage both pathways (although some programs are more didactic than others). This way offers a great chance to “bed in” and get exposed to a different way of doing things.

There is a greater emphasis on the value of research and development projects in the US. The clinical chemist is much more “hands-on” when it comes to assay development, and the importance and time allocated to development work on clinical instrumentation is heavily supported by our technical colleagues, who make their knowledge and expertise freely available. In contrast, clinical laboratories in the NHS are under more financial pressures than their UK equivalents. Any redundancy in equipment time (e.g. LC-MS/MS systems) is used to fulfil the necessary demands of the increasing service workloads, and not for research and development projects. In addition, staffing pressures, particularly on the technical side also adds to the problem.

The actual career grade structure in the two countries is very different. In the UK, a biochemist usually typically spends 3 to 4 years in a pre-registration (trainee) post. Then they must move through the senior and principal grades (so called “middle-grades”) before gaining enough experience to take a consultant grade position, which may eventually culminate in a directorate role. This whole process, from entry into training to consultant may take decades. In the US, a post-doctoral fellow may apply for associate director positions as early as 12 months into their training. Therefore, the associate director position is the first senior post the clinical chemist will undertake with considerable management responsibility. The number of years a chemist spends at this career grade is up to the individual. Associate directors may eventually become laboratory directors, the apex position in the career pathway. The rise to a directorate role in the US may be achieved considerably more quickly than their UK counterparts. One major difference between US and UK labs are the numbers of clinical chemists in a department. Large laboratories within teaching hospitals in the UK may have as many as 10 or 12 biochemists, mostly middle-grades. In contrast, a similar laboratory in the US may have as few as 1 or 2 equivalents. However, this was not always the case; a large re-structuring exercise was carried out in the US in the early to mid-1990s, where departments with 5 or 6 clinical chemists were cut to 1 or 2. I can easily see this happening in the UK over the next 10 to 15 years, with the re-structuring of the NHS likely to continue.

The role of the Royal College of Pathologists has become significantly more prominent as a benchmark for career progression in the UK. Fellowship of the College by examination is practically mandatory for scientists who wish to progress to the higher middle-grade career positions. The College examination has been an established “exit examination” for our medically trained chemical pathologist colleagues for many years. Historically, clinical scientists applied to sit this examination when their careers were well established. In recent years however, candidates are sitting the exam just after completion of training, and in some cases, even before formal training has been completed. What was once an examination designed to showcase both knowledge and experience has become a gateway for career progression. In the US, the ABCC examination is typically taken at the end of the 2 years of COMACC training, and is used as a tool of validation. However, progression to the associate director grade is often made without board certification, as long as there is intent to complete this examination once in post.

In summary, I think that working as a clinical chemist in the US is a potentially attractive option for young clinical scientists from the UK who perhaps are out of contract or are struggling to find a senior grade position following training. Unfortunately, in recent years we have witnessed a significant number of trainees leaving the profession completely after completion of their 4 year training program. I think that the US COMACC system offers these people a unique challenge to move forward in their careers and put their skills to good use in a challenging new working environment.